Provider Demographics
NPI:1104838010
Name:GEORGIO, PETER JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:GEORGIO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:PETER
Other - Middle Name:JOHN
Other - Last Name:GEORGIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2263 W BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-0442
Mailing Address - Country:US
Mailing Address - Phone:559-431-8515
Mailing Address - Fax:559-227-2880
Practice Address - Street 1:16835 ALKALI DR
Practice Address - Street 2:SUITE M
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93245-9463
Practice Address - Country:US
Practice Address - Phone:559-924-0460
Practice Address - Fax:559-924-2197
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA266401223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA26640Medicaid